Late onset infection of covered and bare metal arterial stents

The objective was to present the case of a late covered iliac stent late infection and report a comprehensive literature review on diagnosis and outcomes in this setting.

A comprehensive review of the literature was performed through MedLine by two independent reviewers from 1990 to 2020 on reported cases of arterial stent late onset infection over arterial stents. The data about on the risk factors, clinical presentation, treatment and outcomes were collected.

Twenty-two studies were selected as pertinent for the analysis, totalling 24 patients including the indexed case. Infection occurred at a median of 22 months postoperatively (range 2-120 months) over a bare metal stent in 66.7% (n 16) of cases versus 33.3% (n 8) over a covered stent. Clinical presentation included local symptoms (local pain, oedema, petechiae or skin rash) in 21 (87.5%) cases and non-specific systemic symptoms (fever, sepsis, chills and leucocytosis) in 8 cases (33.3%). In 4 cases (16.7%), patients presented with haemorrhagic shock upon arterial rupture. The bacteria most frequently encountered were S. aureus (54.2% of cases). Several factors were supposed to be responsible for the infection including among which procedure-related (non-aseptic technique, lack of prophylactic antibiotics and repetitive punctures at the access site) or related to pre-existing patient's clinical conditions (immunosuppression, diabetes and concurrent infection) have been considered responsible for the infection. Treatment consisted in antibiotics alone (2 patients, 8.3%) or in association with surgical explant, both with or and without revascularization (n 21, 87.5%). In one case, an endovascular coiling was performed. Complications occurred in 29.2% (n 7) of cases and included the need for amputation, bowel resection, endocarditis, pulmonary failure or pneumonia. Overall, three patients (12.5%) died from a septic shock or multi-organ failure.

Intravascular stent infection is a rare but fearsome condition associated with high morbidity and mortality.